Abstract
Depression is very common in adolescence and if not treated properly it can produce long-term negative consequences, such as alcohol and drug abuse, criminal behavior, and even suicide. It is imperative that parents, educators, mental health workers, and the entire society better understand the signs, symptoms, risk factors, and behavior problems associated with depression in adolescence. This paper attempts to provide society with a better understanding of adolescent depression by reviewing the current literature on adolescent depression. This paper defines depression and reviews its symptoms, as well as the genetic, environmental, and social influences of adolescent depression. It also examines gender and racial differences among adolescents with depression and examines treatment options available to depressed adolescents.

Introduction
Everyone has most likely experienced a sad mood at one time or another in their lives. A short period of sadness is not uncommon as humans struggle with the pressures of every day life, such as financial, marital, and job difficulties. Raising children and taking care of aging parents add to the increase in people’s sometimes sad moods. However, it is depression that is of significant concern in our society, today. Many adults experience depression which can result in significant health consequences and even death from suicide. Furthermore, depression is one of the most common disorders that occur among adolescents. Depression affects 5 to 8 percent of adolescents (Son, 2000). Depression can have devastating effects on adolescents. Research indicates that depressed adolescents are at risk for increased illness, low academic performance, difficult family and peer relations, substance abuse, and delinquent behavior (Allen-Meares, Colarossi, Oyserman, & DeRoos, 2003). Also, depression is often associated with suicide among adolescents and suicide is the third leading cause of death for youth ages 15-24 (McCarthy, Downes, & Sherman, 2008). The dangers associated with adolescent depression are evidence that recognizing, understanding, and treating adolescent depression are extremely important. However, while adolescent depression is common it is difficult to recognize. It is imperative that society, especially parents, educators, and mental health professionals understand what adolescent depression is, recognize its symptoms and its causes, as well as recognize the effects depression has on adolescents and the options available in treating adolescent depression.

What is Adolescent Depression?
Depression is an emotional state that involves feelings of great sadness, worthlessness, and guilt. The Diagnostic and Statistical Manual of Mental Health Disorders (4th ed., text revised) (DSM-IV-TR) requires that five out of nine symptoms must be present for at least two
weeks for a diagnosis of depression to be given. These nine symptoms include a sad, depressed mood most of the day, for most days, loss of interest and pleasure in regular activities, difficulties sleeping, lethargy or agitation, loss or increase in weight and appetite, loss of energy, negative self-concept and feelings of worthless and guilt, difficulty concentrating, and recurrent thoughts of death or suicide. The symptoms of either depressed mood, or loss of interest and pleasure must be one of the five symptoms for a depression diagnosis to be made. Other symptoms include low self-esteem, and somatic complaints. Depression is a recurrent disorder and has increased steadily over the last fifty years, especially among adolescents (Davison & Neale, 2001). Within two years, 40% of individuals will experience another depressive episode and within five years 72% will have a recurrent episode. While the DSM-IV-TR diagnosis does not differentiate between adolescents and adults, the symptoms are the same for adolescents for the most part. The requirement of depressed mood most of the day does specifically mention that this mood can appear as an irritable mood among the adolescent population. Adolescents experience more symptoms of somatic complaints, social withdrawal, and irritability rather than a sad mood. Symptoms of depression can also be different for adolescents of different ages. Younger adolescents may have symptoms of anxiety manifested in clinging behaviors, fearfulness, and physical complaints. Furthermore, research indicates that 89% of depressed
adolescents usually show signs of sleep difficulty while 79.5% show appetite and weight disturbances (McCarthy, Downes, & Sherman, 2008).

Risk Factors of Adolescent Depression
It is just as important to understand the risk factors of adolescent depression as it is to recognize the symptoms of it. Young people can become depressed for many reasons. Biomedical risk factors are associated with adolescent depression. This includes a genetic
predisposition to depression. Parental depression or a family history of depression increases the risk that adolescents will also develop depression. Adolescents with chronic illnesses such as diabetes, asthma, or heart disease are also at risk for depression. Another biomedical risk factor is puberty. The hormonal changes during puberty can bring about a depressive episode. Furthermore, girls are twice as likely to experience depression as boys. Using certain drugs such as birth control pills and Acutane for acne has been found to cause adolescent depression, also (Bhatia & Bhatia, 2007).
There are also psychosocial factors that put adolescents at risk for getting depression. Childhood neglect or abuse is one such psychosocial factor. Adolescents who experience physical, emotional, or sexual abuse are at a higher risk for developing depression (Bhatia & Bhatia, 2007). For example, one study by Buzi, Wienman, and Smith reveals that sexual abuse is a significant factor is predicting depression. In this study, adolescents were recruited from teen clinics in the Southwest part of the United States that provide free family planning and reproductive health services to adolescents. Each participant was given a questionnaire that combined several measures from other adolescent risk-behavior surveys. The Reynolds Adolescent Depression Scale (RADS) was used to measure depression symptoms. Two hundred seventy-nine females participated in the study. Forty of the adolescents reported a history of sexual abuse. Forty of the participants scored at or above a raw score of 77 on the RADS which indicates that these adolescents should be evaluated further for depression. This study suggests that sexual abuse is a significant factor is predicting depression (Busi, Weinman, & Smith, 2007). Other psychosocial factors that influence adolescent depression include stressors such as peer pressure, low academic performance, and poverty. Adolescents who experience the loss of a loved one, or have difficult parental or romantic relationships are also at greater risk for depression (Bhatia & Bhatia, 2007). In addition, depressed parents can influence depression in adolescents. Furthermore, adolescents with parents who abuse alcohol or controlled substances are at a higher risk for developing depression (Feldman, 2008). Parental attachment during childhood and adolescence may also play a role in adolescent depression. A study by Maria Cristina Richaud De Minzi examines this notion. Richaud De Minzi examined whether there are differences in the influence of attachment and parent-child relationships on depression, along with other areas. The study examined 1,019 children in elementary schools in Buenos Aires. Each child was tested using the Argentine Scale of Perception of the Relationships with Parents, the Kern’s Security Scale, the Self-Perception Profile for Children, the Dimensions of Depression Profile for Children and Adolescents, and the Louvian Loneliness Scale for Children and Adolescents. Results indicated that parents’ acceptance promotes secure attachment and positive outcomes in children and helps protect them from depression (Richaud De Minzi, 2006). Other psychosocial factors that influence adolescent depression include adolescents who feel unpopular, have few close friends, experience rejection, have to move to another place to live, and change to a new school.(Son, 2000).

Cognitive factors also influence adolescent depression. Negative thinking and low self-esteem can contribute to depression in adolescents. Depressed individuals see themselves as worthless, and undesirable. They also tend to view all of their experiences in negative ways. Adolescents who view themselves, others, and their future negatively tend to be depressed. Charoensuk conducted a study of 812 Thailand students. Charoesnuk administered several questionnaires to test parental bonding, everyday stressors, depressive symptoms, negative thinking, and self-esteem. Negative thinking was assessed using the Crandell Cognitions Inventory and self-esteem was measured using the Rosenburg Self-Esteem Scale.

The results
concluded that among all factors tested, negative thinking was the strongest predictor of depressive symptoms. Self-esteem was also a predictor of depressive symptoms, but this was only the case when negative thinking was a strong factor. Thus, without negative thinking, self-esteem would not be much of an issue in influencing depression (Charoensuk, 2007).
Other factors have been shown to increase the risk of depression. Adolescents who have a history of depression, or smoke are more likely to experience depressive symptoms. In addition, some psychological disorders such as Anxiety Disorder and Attention-Deficit Hyperactivity Disorder, or conduct and learning disorders influence adolescent depression as well (Bhatia & Bhatia, 2007).
Effects of Depression on Adolescents
It is difficult if not impossible to prevent adolescent depression resulting from heredity, or environmental influences like physical or sexual abuse. However, knowledge of the harmful behaviors that result from adolescent behavior may allow parents, educators, and mental health professionals to find preventions for these behaviors among depressed adolescents. Depression has been found to occur along side harmful disorders, such as eating disorders which include obesity, anorexia, and bulimia. Obsessive-compulsive behaviors, anxiety disorders, and conduct, and oppositional-defiant disorders also have been found to be present along with depression. Further, adolescents tend to engage in harmful behaviors, such as smoking cigarettes, alcohol and drug abuse, criminal behavior, and even suicide (Allen-Meares, Colarossi, Oyserman, & DeRoos, 2003). However, it is not clear which comes first, the depression or the harmful behaviors, or vice versa. Many mental health professionals counsel depressed adolescents assuming that depression occurs first followed by harmful behaviors because there is much research indicating this. However, some studies suggest otherwise. For example, a study by Silberg, Rutter, D’Onofrio, and Eaves on the genetic and environmental factors in adolescent substance use revealed that harmful behaviors occurred first, then depression. Their study revealed that their was a greater effect of substance abuse leading to depression than the other way around (Silberg, Rutter, D’Onofrio, & Eaves, 2003). Another study conducted by Teresa Otsuki revealed a different picture. Otsuki studied a sample of Asian Pacific Islander and Non-API American high school students in California. The sample included 13,374 ninth – and twelfth-grade students among 34 high schools in California. Questionnaires were administered in the classrooms of these students. The questionnaire used was the Multiethnic Drug and Alcohol Survey. Self-esteem and depression were measured. Results indicated that both self-esteem and depression were significantly related to substance use (Otsuki, 2003).
Depression has been closely associated with delinquent behavior among adolescents. Many adolescents engage in illegal use of illicit drugs, petty theft, group assault, and truancy. Adolescents who are depressed engage in violent and non-violent crimes, as well as promiscuous

sexual behavior. One study conducted by Ritakallio, Kaltiala-Heino, Kivivouri, Luukaala, and Rimpela investigated patterns of criminal behavior according to depression among repeatedly delinquent adolescents. This study was conducted on 53,524 students aged 14 to 16 years who took part in the Finnish School Health Promotion Study. The study investigated several issues among adolescent depression and delinquent behavior. Specifically, the study examined whether any differences existed in criminal activities between depressed and non-depressed delinquent adolescents. These differences were assessed by comparing the frequency of self-reported delinquent behavior among both groups. Results indicated that depression was associated with repeated delinquency, and both depressed boys and girls repeated delinquent behaviors more frequently than non-depressed boys and girls. Depression was also associated with a variety of delinquent behaviors. Depressed adolescents tended to engage in more types of delinquent behaviors as well as more violent crimes than did non-depressed adolescents (Ritakallio, Kaltiala-Heino, Kivivuori, Luukkaala, & Rimpela, 2006).
Probably the most serious consequence of adolescent depression is suicide. Suicide is the leading cause of death in adolescents ages 15 to 19 and the third leading cause of death among all adolescents, just falling behind accidents and homicides. White males are at the highest risk of suicide, but African Americans are not following far behind. While suicide occurs at higher rates for boys, girls attempt suicide more often. Suicide attempts by boys usually cause automatic death because of the methods used to commit suicide, such as using guns. Girls usually attempt suicide using less violent methods, such as a drug overdose. While there are many reasons for such a high rate of suicide among adolescents, such as peer pressures, and stress, depression is a major factor as well. With such a high risk of suicide among adolescents it is important that society recognizes the risk factors and warning signs of suicide, as well as depression. Risk factors for suicide include having attempted suicide before, depression that includes strong feelings of helplessness and hopelessness, additional psychiatric problems such as conduct disorder, alcohol and substance abuse, stressful life events such as family difficulty or divorce, and access to firearms. There are several warning signs that are important to recognize regarding adolescent suicide. These warning signs include adolescents who talk about suicide, or dying, difficulty with school such as poor academic performance, or low attendance, making arrangements such as giving away personal belongings, writing a will, loss of appetite or over eating, depression, sleep difficulties that include not being able to sleep, or sleeping all the time, extreme changes in behavior, and a preoccupation with death in music, art, and literature (Feldman, 2008).

The prevention of suicide is of great importance. Parents, educators, doctors, and mental health professionals can do a lot in preventing adolescent suicide. Feldman offers several suggestions. One important suggestion is to talk and listen to the person that is contemplating suicide. Just listening in a non-judgmental way can help adolescents talk through their issues. Also, it can be helpful to talk specifically about suicide with a suicidal person. Getting specific information such as how the person plans to commit suicide, whether they have a gun or pills, and where they keep them can be important information in keeping the adolescent from committing suicide. Evaluating the seriousness of the adolescent’s claims and behaviors is important as well. If the person is in serious danger, do not leave them alone. Being supportive also helps. Just letting the person know you are there for them and care about them, and attempting to break down that person’s isolation feelings is important. Seek professional help for this person. Remove all dangerous objects out of reach of this person, such as guns, razors, scissors, and medication. Call for help immediately, do not keep it secret. Do not try to call the suicidal person’s bluff by daring them to attempt suicide to make them aware of the wrong thinking because this sometimes can cause the person to actually do it. Contracting with the suicidal personal that he or she promises not to attempt suicide until talking with someone can help. It is important to not be fooled by a suicidal person’s sudden improvement. It is still imperative to seek professional help for them because the issues are probably still there (Feldman, 2008).Gender, Ethnic, and Racial Differences
There are many gender, ethnic, and racial differences among adolescents with depression. On average, more girls than boys are depressed. African Americans, and Native Americans have been found to have higher rates of depression than whites. However, whites and Asians are more likely to be depressed when under stress than African Americans or Hispanics. Factors that lead to higher depression in girls may be the drop in their self-esteem during middle school due to peer and media pressure to be more attractive, thin, and to value relationships over academic or career achievements. Ethnic and racial differences in adolescent depression may occur due to the fact that minorities experience significant stressors such as poverty and discrimination. Furthermore, due to lack of financial and social resources, African Americans, Hispanics, and Native Americans have difficulty keeping healthy. They may have more illness such as colds, and are at more risk for developing chronic illnesses, such as diabetes and heart disease. These illnesses contribute to depression (Feldman, 2008). Brown, Elder, and Meadows conducted a study on race-ethnic inequality and psychological distress in adolescents. The study examined

adolescents in grades 7 through 12 from across the United States. The sample included 10, 718 females (52% White, 24% African American, 17% Hispanic, 7% Asian) and 9,948 males (52% White, 22% African American, 18% Hispanic, 8% Asian). Depression was measured in these adolescents using a variation of the Center for Epidemiological Studies Depression Scale. Stressful life events, coping and problem solving skills, mother’s social support, and age was also measured. Results indicated that depressive symptoms varied dramatically across race and ethnic groups. Whites scored the lowest depressive symptoms while Hispanics and Asians scored the highest levels. African Americans scored levels in between whites, Hispanics and Asians. In addition, this study revealed higher scores of depressive symptoms in females than males (Brown, Elder, & Meadows, 2007).Prevention and Treatment for Adolescent Depression
There are three factors that provide protection and help adolescents cope with depression and the struggle of the transition period of adolescence itself. First, positive relationships with parents and friends provide adolescents with a good support system to help them cope with stress. As stated earlier, parents are significant in producing positive outcomes and high self-esteem in their children. In addition, adolescents who have close friends tend to not be depressed like those who have few close friends. Second, adolescents who find a particular area of competence or expertise cope with stress and depression better. Participating in sports, music, art, and other activities provide adolescents with friends and boost their self-confidence if they do well, and can create a sense of belonging if the identify with a team or group. Participating in these positive activities and others, such as shopping, going out with friends, watching television, or taking up a hobby such as collecting coins, or scrap booking can relieve stress and keep
adolescents from participating in harmful behaviors, such as smoking, drinking, or stealing. Lastly, adolescents who feel needed and take on a responsibility role for others such as responsibility to a younger sibling or to a team cope better with stress which may prevent depression (Craig & Baucum, 2002). McCarthy, Downs, and Sherman conducted a study to identify many factors, specifically persons’ sources of assistance, and helpful and unhelpful factors of treatment. The study included a sample of students ages 20 to 23 that had been diagnosed with adolescent depression at ages 15 to 18. These students were administered a questionnaire that reflected the DSM-IV-TR criteria for major depression. They also were administered the Beck Depression Inventory-II which assessed the level of depression of the students. The data was analyzed mostly through a five step analytic process outlined by McLeod. Other guidance came from the work of Strauss, Polkinghouse, and suggestions form the Journal of Counseling and Development. McCarthy, Downs, and Sherman reported that five themes emerged from their data. They found that the participants found talking to someone to be helpful, such as talking to a counselor. The participants felt that just being able to sit down and discuss their depression without having to have a reason for the depression was helpful. A second theme was the relief and respect that occurred. The participants attributed their decrease in depressive symptoms to the therapy with the counselor rather than just the medication. Another theme that emerged had to do with parental an adult partnerships. Most of the participants depended on the parents to help them rather than rejecting them. Participants said the parental support of their parents being involved with therapy just by driving them to an appointment, for example was helpful. Helpful friends were important to the participants as well. Finally, participants seemed to possess a realistic optimism. The participants knew that the depression would reoccur, but
they were not negative about it. They were realistic about the return of the depression being a real possibility, but were optimistic about how to handle it (McCarthy, Downes, & Sherman, 2008).
However, the above factors will not always protect adolescents from depression. Therefore, one must look to all the treatment options available to adolescents once they have become depressed. Psychotherapy, pharmocycotherapy, and education for the parents and family are significant.
Cognitive-Behavioral Therapy, and interpersonal therapy can help adolescents cope with depression. Cognitive-Behavioral therapy is considered first before using drugs to treat depression in adolescents. Cognitive-Behavioral Therapy helps patients recognize distortions in thoughts about themselves and the way others see them. Cognitive-Behavioral Therapy is seen as better than other methods in the treatment of adolescent depression. However, interpersonal psychotherapy is used in the treatment of adolescent depression as well. It involves helping adolescents focus on areas of difficulty in their lives, such as grief, arguments with others, and transitions. Children and adolescents ages 10 to 14 with mild depressive symptoms responded well to therapeutic intervention. Other studies reveal that adolescents ages 13 to 17 do well with Cognitive Behavioral Therapy, but children younger than 9 years of age may not benefit from this therapy due to their verbal and cognitive limitations. Other therapies are helpful in treating adolescent depression including play therapy, family therapy, and group therapy (Dopheide, 2006).
Treatment of adolescent depression with antidepressant medications is another option. Selective serotonin reuptake inhibitors (SSRIs) have been approved by the Food and Drug
Administration (FDA) for treating adolescent depression. Fluoxetine is one antidepressant approved by the FDA in treating depression in children 8 years or older. In the study, Treatment of Adolescents with Depression Study, the combination of Cognitive-Behavioral Therapy and fluoxetine was shown to be better at reducing depressive symptoms among adolescents ages 12 to 17 during a 12 week study than Cognitive-Behavioral Therapy or fluoxetine alone. Sertaline is another antidepressant medication commonly used to treat adolescent depression. However, it is used less commonly since the FDA issued warnings about increased suicidal risks associated with antidepressants. The FDA approved its use for the treatment of obsessive-compulsive disorder in children ages six years and older. Sertaline has lower risks of drug interactions than fluoxetine, but its effectiveness in treating depression lags behind fluoxetine. Paroxetine was the drug most commonly used to treat adolescent depression in 2002. However, the FDA found that adolescents taking paroxetine were at a higher risk of developing suicidal behavior, so the FDA issued a warning in June 2003 that paroxetine should not be used to treat pediatric depression. Citalopram is being studied as an option for treating adolescent depression because it has a low risk of drug interactions compared with the other drugs, but its use is still being investigated. Fluvoxamine has been approved by the FDA for treatment of obsessive-compulsive disorder in children 8 years of age and older. It has been effective in decreasing depressive symptoms as well as binging, purging, and anxiety (Dopheide, 2006). However, parents and pediatricians may be somewhat reluctant to use antidepressants in adolescents due to adverse reactions and side effects. SSRI side effects include mild stomach upset, or adolescents may become sedated. Frontal lobe symptoms such as disinhibition, apathy, and indifference can occur if too much medication is given. Serotonin Syndrome which can be deadly is of concern as well. There are
many other drugs that have been studied for their effectiveness in treating adolescent depression and some are and are not approved by the FDA (Son, 2000).
Trycyclic drugs were the first drugs available in treating adolescent depression. These drugs have been effective in treating attention-deficit hyperactivity disorder and obsessive-compulsive disorder. However, clinical trials showed no significant difference in using these drugs versus using a placebo in the treatment of depression. The potential cardio toxicity side effects and anticholingeric concern has led to trycyclic drugs being used second to SSRIs in treating depression. Another harmful side effect of trycyclic drugs is weight gain. Sudden death has occurred in some children as well (Son, 2000).
Due to the numerous side effects and dangers in using psychotropic drugs, it is important that families and caregivers exercise caution and are aware of warning signs of the dangers in persons taking these drugs. A medication guide should come with all medications and should provide danger signs to look. These include looking for suicidal thoughts or behaviors, behavioral changes or increase in suicidal thoughts, depression, anxiety, panic attacks, or agitation. It is also important to be aware of signs of restlessness, aggression, anger, violence, impulsive behavior, and moodiness. Furthermore, careful monitoring from a clinician is beneficial in preventing suicidal behavior in adolescents on antidepressants (Dopheide, 2006).
Patient and family education is another important treatment option for adolescents with depression. Education providing a better understanding of depression and its risks provides several benefits. For example, patients may be more willing to comply with therapy if they know all the facts and seriousness of their disorder. Also, it may relieve guilt in parents who feel that their child’s depression is their fault and it may also help parents be more aware of
depressive and suicidal symptoms. This education would benefit the adolescent’s entire social support network, including teachers, pediatricians, pastors, coaches, and the like (Son, 2000).Conclusion
A majority of adolescents have and cope with depression every day. Adolescent depression can be difficult to recognize and treat, but it does not have to be a death sentence for them. Suicide rates are high among adolescents and depression is a major factor that increases the risk of suicide. However, parents, educators, coaches, mental health professional as well as all of an adolescent’s support system who is armed with the knowledge and understanding of depression, its symptoms, causes, risks, and treatment options can help defend adolescents against this serious disorder.

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